The Predictive Value of Pirani Scoring System in the Management of Idiopathic Club Foot by Ponseti Method

摘要

The purpose of this study is to determine the predictive value of Pirani scoring system in the management of idiopathic club foot by Ponseti method.A total number of 50 feet in 30 patients of clubfoot were studied and rated according to Pirani scoring system prospectively at Guru Govind Singh Hospital, M.P.Shah Medical College, Jamnagar during the period of April 2005 to April 2008 by Ponseti method performed by a single surgeon. Tenotomies were performed in 31 of 50 feet (62%). Out of 20 feet with a Pirani score greater that or equal to 5.0 at initial presentation, 90% required tenotomy. The mean number of the casts required was significantly greater (range 6-9 casts) for tenotomy group than that of the non-tenotomy group (range 4-6 casts). Following the removal of the final cast, no significant differences were found between the tenotomy and non tenotomy group with reference to Pirani score system. Introduction Idiopathic clubfoot is a complex deformity that is difficult to correct. The deformity has four components: Forefoot Equinus, Hindfoot Varus, Forefoot Adductus and Midfoot Cavus. The Ponseti serial corrective cast management is an easy, effective and economical method of idiopathic club foot management. The deformity is corrected by weekly serial corrective cast manipulation. The aim of the treatment is to reduce or eliminate all the components of the CTEV deformity to obtain Painless, Plantigrade, Pliable and Cosmetically and Functionally acceptable foot within the minimum time duration and least interruption of the socio-economical life of the parents and child. There is nearly universal agreement that the initial treatment of the Clubfoot should be non-operative regardless of the severity of the deformity. Ponseti Method1 which involves serial corrective manipulation, a specific technique of the cast application, and a possible percutaneus Tendo-Achillis tenotomy. The method has been reported to have short-term success rate approaching 90% and long-term results have been equally impressive12There is no agreed method of grading the severity of the deformity or monitoring the natural history, but there is a reported need of such classification,345 which should be reliable, reproducible, feasible in a clinical setting and predict appropriate treatment.3 Pirani et el6 provide a simple scoring system based on six clinical signs of contracture. Three clinical signs for Midfoot include curved lateral border, medial creases and position of the lateral part of the talar head. Three clinical signs for Hindfoot include posterior creases, rigid equinus and empty heel. Each is scored according to the following principle:0, no abnormality.0.5, moderate abnormality.1, severe abnormality.Thus, each foot can receive a Midfoot score between 0-3 and a hindfoot score between 0-3 and a total score between 0-6.Scher et al7 compared Pirani et al6 and Dimeglio et al8 scores with the need for a tenotomy. They concluded for both systems that there is a link between high scoring foot and the need for tenotomy. 85% of the feet with Pirani severity score above 5 required tenotomy, which is significantly more than those that did not required the same.Parents whose children are starting Ponseti treatment are likely to enquire about the number of the casts to correct the deformity and about the requirement of the tenotomy later on during treatment. The aim of this study is to know whether Pirani severity score will allow the surgeon to give more specific answers of these questions or not during the early stages of Ponseti treatment. Patients and Methods A total number of 50 feet in 30 patients of clubfoot were studied prospectively at Guru Govind Singh Hospital, M.P.Shah Medical College, Jamnagar during the period of April 2005 to April 2008 by Ponseti method performed by a single surgeon. Corrective serial casts are applied after doing proper manipulation according to the Ponseti method18910. Treatment is started as soon as possible after referr